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Nuts and your health
Dr. Peter Pribis
2014
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Adventist Health Study
Fraser GE, Sabate J, Beeson WL & Strahan MT. A possible protective effect of nut consumption on risk of coronary heart disease: the Adventist Health StudyArch Inter Med 1992; 152:1416-1424
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Adventist Health StudyAll participants (%)
Man Woman
Nuts: < 1/week 35.8 37.6
Nuts: 1-4/week 41.4 39.7
Nuts: > 5 week 22.8 22.7
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Adventist Health StudyVegetarian participants (%)
Men Women
Nuts: < 1/week 20.2 23.7
Nuts: 1-4/week 44.9 42.6
Nuts: > 5 week 34.9 33.7
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Nuts consumption and risk of MI
Adjusted for age, gender, smoking, exercise, weight, hypertension, consumption of whole wheat bread and beef
*p<0.005; ** p<0.0001
Non-fatal MI Fatal MI0
20406080
100100 100
78 76
49 52
< 1 week 1-4 week > 5 week
% r
isk
of M
I
* **
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Nuts consumption and risk of MI
Adjusted for age*p<0.001; § p<0.001 for Trend
Man Woman0
20406080
100100 100
82
5840
54
< 1 week 1-4 week > 5 week
% r
isk
of M
I
*§
§*
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Nuts consumption and risk of MIAdjusted for age and gender
*p<0.001; **p<0.05; § p<0.001 for Trend; † p<0.05 for Trend
Vegetarians Omnivore0
20406080
100100 100
59
98
42 50
< 1 week 1-4 week > 5 week
% r
isk
of M
I
**§ †*
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Nuts consumption and risk of MIAdjusted for age and gender
*p<0.001; § p<0.001 for Trend
Age < 80 Years Age > 80 Years0
20406080
100100 100
89
5648 45
< 1 week 1-4 week > 5 week
% r
isk
of M
I
*§* §
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Nuts consumption and risk of MIAdjusted for age and gender
*p<0.001; **p<0.01; § p<0.01 for Trend; † p<0.001 for Trend
BMI < 24 BMI > 240
20406080
100100 100
5979
44 50
< 1 week 1-4 week > 5 week
% r
isk
of M
I
*** §†
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Nuts and cancer• Adventist with the highest nut
consumption have the lowest mortality• Nuts consumption promotes longevity
Fraser GE, Sabaté J, Beeson WL. Nuts, nuts good for your heart...? Arch Intern Med 1992;152: 2507-8.
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Walnuts and serum lipid levels
Sabaté J, Fraser GE, Burke K, Knutsen SF, Bennett H & Lindsted KD. Effects of walnuts on serum lipid levels and blood pressure in normal men. N Engl J Med 1993;328: 603-7
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The Walnuts StudyStudy Design
• 18 Men• Age 21 - 43 years (mean 30 years)
• BMI 18.7 - 30.6 ( mean 23.8)
• Cholesterol (range) 137 - 250 mg/dl (3.54-6.47 mmol/l)
• Blood pressure (mean) 109 / 72 mm Hg
5 days 4 weeks 4 weeksIntroduction First period Second period
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Meal Plan
Energy: 2500 - 2600 Kcal/Day
Fatty acids:Saturated: 6-9 g/DayMono: 7-8 g/DayPoly: 9-16 g/Day
ReferenceWalnuts
0
25
50
75
100
5654
1414
3032
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Total cholesterol (mg/dl)
Run-in First period Second period140
154
168
182
196
210202
180 185198
160158
Reference Walnuts
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LDL-Cholesterol (mg/dl)
Run-in First period Second period859095
100105110115120
112
9495
115
Walnuts Reference
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HDL-Cholesterol (mg/dl)
Run-in First period Second period20
28
36
44
52
60
48 47
4541
Walnuts Reference
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• Nurses Health Study• Health Professionals Follow Up Study• Iowa Women’s Health Study• Cholesterol and Recurrent Event Study
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The story of statins reversed
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Adventist Health StudyMultivariate estimates of effects of high- vs. low-risk values of individual behavioral risk factors
Fraser GE & Shavlik DJ Ten years of life? Does it matter. Arch Intern Med 2001;161:1645-52
Contrasts Difference in Life Expectancy (95% CI)Men Women
Vegetarian : Non-vegetarian 1.53 (0.41-2.65) 1.51 (0.53-2.50)High exercise : Low exercise 2.73 (1.41-4.06) 1.88 (0.86-2.90)
Nuts > 5/ Week : Nuts < 1/Week 2.74 (1.60-3.88) 1.87 (0.72-3.02)Medium tertile BMI : High tertile BMI 1.41 (0.34-2.49) 2.25 (1.27-3.23)
Never smoker : Past smoker 1.25 (0.44-2.07) 1.80 (0.56-3.04)HRT ever : HRT never 1.06 (0.27-1.86)
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Nut Consumption and Total and Cause-Specific
Mortality Bao Y, Han J, Hu FB, Giovannucci EL, Stampfer MJ, Willett WC & Fuchs CS. Association of Nuts Consunption with Total and Cause-Specific Mortality. N Engl J Med 2013;369: 2001-11
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Methods
• Cohort studies • Nurses Health Study (76,464 nurses)
• Health Professionals Follow-up Study (42,498 physicians, dentist, pharmacist, veterinarians)
• Nuts intake updated every 2 to 4 years
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Selected Characteristics of Participants According to Frequency if Nuts
ConsumptionCharacterictics Never < 1
Week 1/Week 2-4/Week 5-6/Week 7>/Week
Age (yr) 57.4 ±11.4
60.1 ±10.9
60.8 ±10.9
62.0 ±10.8
62.7 ±11.1
61.8 ±11.5
Physical activity (MET/wk)
19.2 ±28.9
20.4 ±27.5
25.2 ±32.5
28.5 ±34.9
31.3 ±38.4
34.3 ±42.3
BMI 26.0 ±5.1
26.1 ±5.0
25.9 ±4.6
25.6 ±4.4
25.2 ±4.2
24.9 ±4.1
Fruit intake (servings/day)
2.1 ±1.4
2.1 ±1.2
2.3 ±1.3
2.5 ±1.4 2.8 ±1.6 2.9
±1.7Vegetable intake (servings/day)
2.4 ±1.4
2.6 ±1.3
2.9 ±1.4
3.2 ±1.5 3.4 ±1.6 3.4
±1.8
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Never < Once/week Once/week 2 to 4/week 5 to 6/week 7/week
0.7
0.8
0.9
0.9
1.01.00
0.94
0.88
0.850.88
0.79
Total Mortality According to Frequency of Nut Consumption in Woman
(p<0.001)
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Never < Once/week Once/week 2 to 4/week 5 to 6/week 7/week
0.7
0.8
0.9
0.9
1.01.00
0.91 0.910.89
0.83
0.80
Total Mortality According to Frequency of Nut Consumption in Man
(p<0.001)
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Never < Once/week Once/week 2 to 4/week 5 to 6/week 7/week
0.7
0.8
0.9
0.9
1.01.00
0.93
0.890.87
0.85
0.80
Total Mortality According to Frequency of Nut Consumption(Pooled)
(p<0.001)
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Walnuts and Cognition Pribis P, Bailey RN, Russell AA, Kilsby MA, Hernandez M, Craig WJ, Grahales T, Shavlik DJ & Sabate J. Effects of Walnuts consumption on cognitive performance in yong adults Br J Nutr 2012; 107(9): 1393-1401
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Experimental groupWalnuts8 weeks
Control groupPlacebo8 weeks
Environmental control groupNo dietary intervention
8 weeks
Control groupWalnuts8 weeks
Experimental groupPlacebo8 weeks
Environmental control groupNo dietary intervention
8 weeks
Washout period6 weeks
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Category n (%)
Males 39 (41)33 (43)
Females 57 (59)44 (57)
Gender distribution
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Experimental Placebo Environmental p
Age (years) 20.6 ± 2.0 20.7 ± 2.1 20.0 ± 1.9 0.362
Hours of sleep (h/day) 7.2 ± 1.3 7.0 ± 0.7 7.0 ± 1.0 0.747
BMI (kg/m2) 22.6 ± 3.3 23.2 ± 3.5 23.1 ± 4.1 0.776
Omega-3 intake (g) 0.7 ± 1.1 0.6 ± 0.6 0.7 ± 1.0 0.788
Selected characteristics
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Category n (%)
Caucasian 41 (43)
African-american 21 (22)
Hispanic 13 (14)
Asian 10 (11)
Mixed 9 (10)
Ethnicity
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Category n (%)
Freshman 24 (25)
Sophomore 21 (22)
Junior 26 (27)
Senior 18 (19)
Graduate 7 (7)
Class standing
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Category n (%)
Vegan 7 (7)
Lacto-ovo-vegetarian 25 (26)
Pesco-vegetarian 2 (2)
Non-vegetarain 62 (65)
Vegetarian Status
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• 385 kcal• 20 g walnuts
• 2.52 g ALA• 3 slices 1040 kcal /60 g (1/2 cup)
walnuts
• 287 kcal• No walnuts
• 0.21 g ALA• 3 slices 775 kcal
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Food displacement
• Males - less milk, cereals, pasta, bread• drunk more soy and rice milk
more
• Females - less milk, cheese, dried fruits, cereals
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Patterns in the test meal consumption
One Two Three
52%
26% 22%
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Patterns in the test meal consumption
Breakfast Lunch Dinner Snacks
42%
19% 19% 20%
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Trend in weight week 1 to 8Males 1.8 kg (3.9 lb) ± 1.3; Females 0.7 kg (1.5 lb) ± 0.8; p = 0.000
Week 01 Week 02 Week 03 Week 04 Week 05 Week 06 Week 07 Week 08130
138
146
154
162
170162.3
164.6 165.1 165.9 165.7 165.3 166.1 166.3
139.1 139.8 139.8 141.3 139.9 139.6 139.9 138.5
Males Females
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Trend in weight week 9 to 16Males 0.7 kg (1.5 lb) ± 2.3; p = 0.228 / Females 0.3 kg (0.6 lb) ± 1.4; p = 0.287
Week 09 Week 10 Week 11 Week 12 Week 13 Week 14 Week 15 Week 16130
138
146
155
163
171168.8 169.7
164.1
169.6 169.2 169.6 168.5170.6
138.1134.8 133.6
137.3 137.1 137.5135.5
138.7
Males Females
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Biological indicatorsPlasma concentration of fatty
acids (µg/mL) Walnuts Placebo p
18:2n-6 (omega 6) 248.3 ± 88.3 223.6 ± 66.4 0.013
18:3n-3 (omega 3) 9.9 ± 6.7 5.9 ± 2.3 <0.001
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WMS-IIIThe Wechsler Memory Scale
• Memory test• Immediate
• Delayed
• Working memory
• Auditory
• Visual
• Recall (unprompted)
• Recognition (prompted)
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WMS-IIIThe Wechsler Memory Scale
• Memory test (11 subcategories)
• Logical memory
• Faces
• Verbal memory
• Numbers
• Family pictures
• Auditory memory
• Immediate memory
• Delayed memory
• General memory
• Auditory memory
• Visual memory
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• No changes• Differences - -3.7 to 2.8 %
• No significance• Norms - 50th to 80th percentile
WMS-III• The Wechsler Memory Scale
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APMRaven’s Advanced Progressive Matrices
• Fluid (decontextualized) intelligence• Non-verbal, clear thinking abilities, logical
reasoning, symbolic thinking, identifying relationships
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APMΔ 0.55% (95CI% -2.70 - 3.80), p=0.735
Series126.0
26.5
27.0 26.926.8
Walnuts Placebo
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APMRaven’s Advanced Progressive Matrices
• Fluid intelligence very stable• Norms
• Males - 81st percentile, IQ 113
• Females - 64th percentile, IQ 105
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WGCTAThe Watson-Glaser Critical Thinking Appraisal
• Crystalized intelligence (contextualized)• Verbal, defining problem, selecting relevant
information, recognizing assumption, formulating hypothesis, evaluate conclusions
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WGCTAThe Watson-Glaser Critical Thinking Appraisal
• Inference• Recognition of Assumption• Deduction• Interpretation• Evaluation of Arguments• Total score
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WGCTABoth sexes
Inference Recognition Deduction Interpretation Evaluation Total0
15
31
46
9.812.4 11.7 12.1 12.2
45.7
8.812.1 11.6 12.1 12
44.1Walnuts Placebo
*
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WGCTA - Inference - Both SexesΔ 11.2% (95CI% 2.86 - 19.55), p=0.009
Walnuts Placebo8.0
9.0
10.0 9.85
8.86
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WGCTA - Inference - FemalesΔ 13.71% (95CI% 1.75 - 25.66), p=0.026
Walnuts Placebo8.0
9.0
10.0 10.01
8.8
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WGCTAThe Watson-Glaser Critical Thinking Appraisal
• Crystalized intelligence unstable• Norms
• Males - 50th percentile
• Females - 30th percentile
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POMSProfile of mood states
• 65 adjectives• 5 point Likert scale - “not at all” to “extremely”
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POMSProfile of mood states
• Six mood domains• Tension-Anxiety (T)
• Depression-Dejection (D)
• Anger-Hostility (A)
• Vigor-Activity (V)
• Fatigue-Inertia (F)
• Confusion-Bewilderment (C)
• Total Mood Disturbance (TMD) - (T+D+A+F+C)-V
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POMSBoth sexes - all differences non-significant
T D A V F C TMD0
8
15
23
30
38
11.2 9.76.4
13.810.2 9.51
33.4
11.8 12.17.4
13.110 9.54
37.8Walnuts Placebo
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POMSMales - Anger-Hostility p=0.013/0.057; TMD p=0.043
T D A V F C TMD0
8
16
24
32
40
9.1 9.46.5
15.6
10 9.3
28.9
11.2 12.89.4
13.710.3 9.9
39.9Walnuts Placebo
*
*
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Fat composition of nuts Total fat
(g)Saturated
fat (g) Mono (g) Poly (g)Almonds
(24 pieces) 14.5 1.5 10 3Hazelnuts (12 pieces) 18 1 15 2
Walnuts (14 halves) 18 2 5 11
Peanuts (35 pieces) 13.5 2 7 4.5
Cashew (18 pieces) 13 2.5 8 2.5Pistachios (47 pieces) 14 2 8 4Pecans (35
pieces) 19 2 12 5
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AlmondAlmonds, raw (prunus dulcis) - 100 g
Source: USDA Nutrient Database for Standard References, 2001
Energy(kcal)
578
Protein (g) 21.26 Fat (g) 50.64 Carbohydrate (g) 19.74
Arginin (g)
2.47Lysin (g)
0.6SFA (g)
3.88MUFA (g)
32.16PUFA (g)
12.21Sugar (g)
4.8Fiber (g)
11.8
Vitamins and phytosterols
Vitamin E (mg)
26.18
Alpha-Tocopherol (mg)
25.87
Beta-Tocopherol (mg)
0.43
Gama-Tocopherol (mg)
0.89
Delta-Tocopherol (mg)
0.25
Riboflavin (mg)
0.81
Folic Acid (mg)29.00
Phytosterols (mg)120.00
Minerals
Calcium (mg)
240.00
Magnesium (mg)275.00
Potassium (mg)728.00
Sodium (mg)
1.00Zinc (mg)
3.36Copper (mg)
1.1
Phosphorus (mg)
474.00
Selenium (microg)4.4
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Conclusion• Daily nuts
consumption protects again fatal and non-fatal MI, stroke, diabetes, possibly cancer, cognitive disorders
• 28-50 g/day (1/4 cup)